Postpolypectomy prophylactic clip closure for the prevention of delayed postpolypectomy bleeding: A systematic review

Abstract

Delayed postpolypectomy bleeding (DPPB) is the most common complication of colonoscopic polypectomy. Prophylactic clipping after an uncomplicated polypectomy is increasingly used, but it is unclear if this results in the prevention of DPPB. This study aimed to review prophylactic clip use and its effect on the rates of DPPB. MEDLINE, Embase, and the Cochran Library were systematically searched for studies (1995–March 2017) that used prophylactic hemoclips and assessed DPPB as an outcome. Of 1402 articles identified, nine papers were eligible for inclusion, evaluating 4311 patients and 7783 polyps; 118 patients experienced a DPPB, and 49 of these patients received prophylactic clips. There was no significant difference in DPPB rates in patients who received prophylactic clipping compared to those who did not (odd ratio: 0.8; 95% confidence interval: 0.36–1.77; P = 0.56). There was also no significant difference in the DPPB of polyps <20 mm compared with polyps ≥20 mm. Clip application for prophylactic management of an uncomplicated polypectomy has not been demonstrated to reduce the risk of DPPB, casting doubt on the use of this costly practice.

Prophylactic Clipping After Colorectal Endoscopic Resection Prevents Bleeding of Large, Proximal Polyps: Meta-analysis of Randomized Trials

“…This inference is a distinct advantage of our analysis, because previous systematic reviews were not powered enough to perform it. [9][10][11][30][31][32] Our analysis showed the clinical relevance of 2 main factors: polyp size and location, on both the absolute risk of PPB and the relative efficacy of clipping, as well as their hierarchical interaction. Our adjusted estimates attributed a nearly 2-fold increase-from 4.3% to 7.6%-in the risk of PPB for lesions !20 mm.…”

Endoscopic Management of Post-Polypectomy Bleeding

“…49 In contrast, in a separate randomized trial in 1,098 patients undergoing polypectomy of nonpedunculated polyps ≥10 mm, there was no benefit with closure of mucosal defects using prophylactic endoscopic clipping in reducing the rate of delayed PPB, and this finding was consistent with that obtained for large polyps (≥20 mm). 50 Several systematic reviews and meta-analyses [51][52][53][54][55][56] have consistently shown a similar lack of benefit of prophylactic endoscopic clipping of mucosal defects of nonpedunculated polyps up to 19 mm, with inconclusive benefits for nonpedunculated polyps ≥20 mm. This heterogeneity in polyps ≥20 mm could be due to variations in the polyp location that have not been accounted for in most studies, as was reported in the previously mentioned randomized trial 49 in which a benefit was noted only in the proximal colon.…”

Endoscopic polypectomy devices

“…Two meta-analyses found no benefit from prophylactic clipping. 63,64 One consistent feature of the negative trials has been minimal bleeding in the control group. There is also heterogeneity in the studies, with polyps of varying sizes, shapes, and pathologies using both standard HSP and EMR.…”